Dementia NICE clinical guideline 42 Implementing the NICE/SCIE guidance

What this presentation covers NICE/SCIE clinical guideline Background and content of the guideline Key priorities and recommendations TA111 updated March 2011 Interventions NICE Quality Standard

National Institute for Health and Clinical Excellence NICE is the independent organisation in the NHS, responsible for producing guidance based on the best available evidence of effectiveness and cost effectiveness to promote health and to prevent or treat ill health.

Social Care Institute for Excellence SCIE develops and promotes knowledge-based practice in social care. It produces recommendations and resources for practice and service delivery and improves access to knowledge and information in social care by working in partnership with others.

Who is this NICE-SCIE guideline aimed at? This is the first joint guideline produced by NICE and SCIE It covers the care provided by social care practitioners, primary care, secondary care and other healthcare professionals who have direct contact with, and make decisions concerning the care of, people with dementia

Dementia Dementia is a progressive and largely irreversible syndrome that is characterised by a widespread impairment of mental function

Need for this guideline 700,000 people are affected in the UK (Alzheimer’s Society) with 5% over 65, rising to 20% of the over 80s Dementia is associated with complex needs and high levels of dependency and morbidity Care needs often challenge the skills and capacity of carers and available services

What the guideline covers Risk factors, screening and prevention Diagnosis and assessment Promoting independence Cognitive symptoms and maintenance of function Non-cognitive symptoms and challenging behaviour Comorbid emotional Disorders Palliative and end-of-life care Palliative Care Interventions Promoting independence Diagnosis

Key priorities Non discrimination Valid consent Carers Coordination and integration of care Memory services

Key priorities continued Structural imaging Behaviour that challenges Training Mental health needs in acute hospitals

Non-discrimination People with dementia should not be excluded from any services because of their diagnosis, age (whether designated too young or too old) or a coexisting learning disabilities

Valid consent Health and social care practitioners should always seek valid consent from people with dementia If the person lacks the capacity to make a decision, the provisions of the Mental Capacity Act 2005 must be followed

Carers The rights of carers to an assessment of needs as set out in the Carers (Equal Opportunities) Act 2004 should be upheld Carers of people with dementia who experience psychological distress and negative psychological impact should be offered psychological therapy, including cognitive behavioural therapy, by a specialist practitioner

Coordination and integration of health and social care Health and social care managers should coordinate and integrate working across all agencies involved in the treatment and care of people with dementia and their carers Care managers/coordinators should ensure the coordinated delivery of health and social care services for people with dementia

Memory services Memory assessment services should be the single point of referral for all people with a possible or suspected diagnosis of dementia Services may be provided by a memory assessment clinic or by community mental health teams

Structural imaging for diagnosis Structural imaging should be used to assist in the diagnosis of dementia, to aid in the differentiation of type of dementia and to exclude other cerebral pathology Magnetic resonance imaging (MRI) is the preferred modality to assist with early diagnosis and detect subcortical vascular changes, although computed tomography (CT) scanning could be used

Behaviour that challenges People with dementia who develop behaviour that challenges should be assessed at an early opportunity to establish the likely factors that may generate, aggravate or improve such behaviour Common causes include depression, undetected pain or discomfort, side effects of medication and psychosocial factors

Training Health and social care managers should ensure that all staff working with older people in the health, social care and voluntary sectors have access to dementia-care training (skill development) that is consistent with their role and responsibilities

Mental health needs in acute hospitals Acute and general hospital trusts should plan and provide services that address the specific personal and social care needs and the mental and physical health of people with dementia who use acute hospital facilities for any reason

Interventions The guideline recommends a range of non-pharmacological and pharmacological interventions for cognitive symptoms, non-cognitive symptoms and behaviour that challenges, and for comorbid emotional disorders Detailed guidance on the use of cholinesterase inhibitors and memantine is set out in TA111

TA111 Alzheimer’s disease Guidance on acetylcholinesterase inhibitors (donepezil, rivastigmine and galantamine ) and memantine for Alzheimer’s disease See for detailswww.nice.org.uk/guidance/TA111 Guidance updated March 2011

Acetylcholinesterase inhibitor: mild to moderate disease initiate under specialist care continue only if worthwhile effect regular review Memantine: moderate disease and intolerant of or contraindication to acetylcholinesterase inhibitors or severe disease Guidance updated March 2011 TA111 Alzheimer’s disease

Acetylcholinesterase inhibitor: Start with the drug with the lowest acquisition cost Alternative if appropriate Guidance updated March 2011

Consider factors that could affect assessment scales and adjust as needed Secure equality of access to treatment Guidance updated March 2011 TA111 Alzheimer’s disease

Do not rely solely on cognition scores if: the patient has learning, other disabilities or communication difficulties the tool cannot be applied in a suitable language there are other similar reasons why the score is not an appropriate measure Guidance updated March 2011

Other interventions Cognitive symptoms of dementia and mild cognitive impairment (MCI) Non-cognitive symptoms and behaviour that challenges People with comorbid emotional disorders

Cognitive symptoms Offer cognitive stimulation programmes for mild to moderate dementia of all types For people with vascular dementia, do not use acetylcholinesterase inhibitors or memantine for cognitive decline, except as part of properly constructed clinical studies For people with mild cognitive impairment (MCI), do not use acetylcholinesterase inhibitors except as part of properly constructed clinical studies

Non-cognitive symptoms and behaviour that challenges Consider medication for non-cognitive symptoms or behaviour that challenges in the first instance only if there is severe distress or an immediate risk of harm to the person or others Use the assessment and care-planning approach as soon as possible For less severe distress and/or agitation, initially use a non-drug option See for detailswww.nice.org.uk/guidance/CG42

Non-cognitive symptoms and behaviour that challenges People with Alzheimer’s, vascular dementia or mixed dementias with mild-to-moderate non-cognitive symptoms should not be prescribed antipsychotic drugs because of the possible increased risk of cerebrovascular adverse events and death People with DLB with mild-to-moderate non-cognitive symptoms, should not be prescribed antipsychotic drugs, because those with DLB are at particular risk of severe adverse reactions

People with comorbid emotional disorders Assess and monitor people with dementia for depression and/or anxiety Consider cognitive behavioural therapy A range of tailored interventions such as reminiscence therapy, multisensory stimulation etc should be available Offer antidepressant medication

Suggested actions Service provision Communication, education and training Integration and coordination of services

Promote incentives to improve implementation using the Quality and Outcomes Framework (QoF) and relevant targets

Communication, education and training Review communication and training arrangements within and across partner organisations Work with mental capacity act networks Use the best practice tool from Department of Health

Communication, education and training Collaborate with your local workforce development directorate, local dementia specialists, social services, higher education institutions and voluntary agencies to consider training in dementia as part of CPD for health and social care staff. Ensure approved social workers’ training contains relevant material.

Costs and savings Psychological therapies: £27.4 million Structural imaging: £20.2 million EEG: –£6.9 million Joint working: not quantified nationally Training: not quantified nationally

Access tools online Slide set Implementation advice Audit criteria Costing report Costing template Available from

Access the guideline online The quick reference guide – a summary of the recommendations for health and social care staff ‘Understanding NICE-SCIE guidance’ – information for people with dementia and their carers The NICE-SCIE guideline – all the recommendations The full guideline – the recommendations, how they were developed and summaries of the evidence The NICE quality standard on dementia Available from and

Further information from SCIE Practice guides – summaries of information on a particular topic to update practice at the health and social care interface Research briefings – information, research and current good practice about particular areas of social care Available from

Further resources from SCIE

NICE Quality Standard Dementia

Quality standards A quality standard is a set of specific, concise statements that: act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources are produced collaboratively with the NHS and social care, along with their partners and service users

Dementia quality standard This quality standard provides clinicians, managers and service users with a description of what a high-quality dementia service should look like It describes markers of high-quality, cost effective care that, when delivered collectively, should contribute to improving the effectiveness, safety, experience and care for adults with dementia The quality standard consists of 10 quality statements

Quality statement 1 People with dementia receive care from staff appropriately trained in dementia care Quality measure Process: Proportion of staff working with people with dementia who have dementia care training

Quality statement 2 People with suspected dementia are referred to a memory assessment service specialising in the diagnosis and initial management of dementia Quality measure Process: Proportion of people with suspected dementia who are referred to a memory assessment service specialising in the diagnosis and initial management of dementia

Quality statement 3 People newly diagnosed with dementia and/or their carers receive written and verbal information about their condition, treatment and the support options in their local area Quality measure Process: Proportion of people newly diagnosed with dementia receiving written and verbal information about their condition, treatment and the support options in their local area

Quality statement 4 People with dementia have an assessment and an ongoing personalised care plan, agreed across health and social care, that identifies a named care coordinator and addresses their individual needs Quality measure Process: a)Proportion of people with dementia whose individual needs are assessed and whose care plan states how those needs will be addressed. b)Proportion of people with a named health or social care coordinator

Quality statement 5 People with dementia, while they have capacity, have the opportunity to discuss and make decisions, together with their carer/s, about the use of: advance statements, advance decisions, to refuse treatment, lasting power of attorney, preferred priorities of care

Quality statement 5 continued Quality measure Process: Proportion of people with dementia while they have capacity and their carer/s, who are given the opportunity to discuss with health and social care professionals, the use of: advance statements, advance decisions to refuse treatment, lasting power of attorney and preferred priorities of care

Quality statement 6 Carers of people with dementia are offered an assessment of emotional, psychological and social needs and, if accepted, receive tailored interventions identified by a care plan to address those needs Quality measure Process: a)Proportion of carers of people with dementia who are offered an assessment of their needs b)Proportion of carers of people with dementia receiving interventions tailored to their needs

Quality statement 7 People with dementia who develop non-cognitive symptoms that cause them significant distress, or who develop behaviour that challenges, are offered an assessment at an early opportunity to establish generating and aggravating factors. Interventions to improve such behaviour or distress should be recorded in their care plan

Quality statement 7 Quality measure Process: a)Proportion of people with dementia who develop non-cognitive symptoms that cause significant distress, or who develop behaviour that challenges, who receive an assessment to establish likely factors that may generate, aggravate or improve such distress or behaviour.

Quality statement 7 Quality measure Process: b)Proportion of people with dementia who develop non-cognitive symptoms that cause them significant distress, or who develop behaviour that challenges, with an individualised care plan identifying actions to address the distress or behaviour.

Quality statement 7 Quality measure Process: c)Proportion of people with dementia with mild-to- moderate non-cognitive symptoms who are prescribed anti-psychotic medication. (Goal to be 0% reflecting the Department of Health report on the use of anti-psychotic medication for people with dementia and its aim to reduce the use of anti-psychotic medication for people with dementia.)

Quality statement 8 People with suspected or known dementia using acute and general hospital inpatient services or emergency departments have access to a liaison service that specialises in the diagnosis and management of dementia and older people’s mental health

Quality statement 8 Quality measure Process: Proportion of people with suspected or known dementia using acute and general hospital facilities that are assessed by a liaison service that specialises in the diagnosis and management of dementia and older people’s mental health

Quality statement 9 People in the later stages of dementia are assessed by primary care teams to identify and plan their palliative care needs Quality measure Process: Proportion of people in the later stages of dementia whose palliative care needs are assessed by primary care teams and the resulting information is communicated within the team and with other health and social care staff

Quality statement 10 Carers of people with dementia have access to a comprehensive range of respite/short-break services that meet the needs of both the carer and the person with dementia Quality measure Process: Proportion of carers of people with dementia who access respite/short-break services when required

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